SSA - POMS: DI 26510.015 - Completing Item 16A and 16B (Primary and Secondary Diagnosis, Body System Code, and Impairment Code) on the SSA-831 Disability Determination and Transmittal

A. Citing a diagnosis

Correct diagnosis coding is essential for statistical analysis, case studies, and answering public inquiries. The following principles apply when citing a diagnosis:

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The diagnosis should identify the underlying cause (i.e., etiology) and disabling manifestation.
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If the underlying cause is unknown, the diagnosis should identify the disabling manifestation.
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You must include the codes most relevant to the determination.
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Document additional information in a Case Note in the Disability Case Processing System (DCPS), or on the Case Development Worksheet (CDW)

1. Disability examiner (DE) and medical or psychological consultant (MC/PC) team determinations

The reviewing MC/PC and DE team determines the diagnosis and its nomenclature. They provide the diagnosis based on a review of all the medical evidence in file and choose the terminology used on the determination form. The MC/PC completes or reviews the diagnosis. The MC/PC is responsible for diagnosis terminology and accuracy.

2. Non-team determinations

When the DE alone is responsible for the determination, the DE is responsible for diagnosis terminology and accuracy.

B. Block 16A. Primary Diagnosis and Block 16B. Secondary Diagnosis on Form SSA-831

Block 16A. and 16B. on the SSA-831 contain entries for a:

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primary and a secondary diagnosis,
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2-digit primary body system identifying code, and
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4-digit primary and a secondary impairment identifying code – based on a simplified version of the International Classification of Diseases (ICD) full code.

C. Determining the primary and secondary diagnoses

Complete items 16A and 16B as follows:

1. Diagnosis code based on medical evidence

Evaluate all of the medical evidence in the file, and determine diagnoses for the period reviewed. Enter the diagnosis of the claimant's primary and secondary impairment (if any) at the established onset date (EOD) in an allowance or at the alleged onset date (AOD) in a denial. Include other diagnoses present at the time of adjudication in the determination rationale.

2. Primary diagnosis or Item 16A

The primary diagnosis in an allowance refers to the basic condition that rendered the person disabled, or in a denial, the one that the evidence shows to have the most significant effect on the person's ability to work.

When the case is a denial, and no diagnosis is established, enter “none established.” Use impairment code “0000” when there is no medical evidence in the file. Use impairment code “6490” when medical evidence in the file is not sufficient to establish a diagnosis.

a. Drug addiction and alcoholism (DAA) materiality

When the case is a denial because DAA is material, enter the appropriate code for “alcoholism” (3030 – Substance Addiction or Psychoactive Substance Dependence Disorders (Alcohol)) or “drug addiction” (3040 – Substance Addiction or Psychoactive Substance Dependence Disorders (Drugs)) as the primary impairment. When the case is an allowance because DAA is not material, enter the mental or physical impairment that would be disabling, absent the effects of DAA, as the primary diagnosis.

b. Statutory blindness

IMPORTANT: A claimant has statutory blindness only if the visual disorder meets Listing 2.02 or 2.03A for adults, or Listing 102.02 or 102.03A for children.

Use the term “Statutory Blindness” as the primary diagnosis.

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Enter body system “02” and impairment code “3694” in the blocks provided.
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In Item 16B (Secondary Diagnosis), show the underlying cause of the blindness and the corresponding diagnosis code.
3.

Enter “Statutory Blindness” as the secondary diagnosis when the basis of the EOD is a different impairment and that impairment’s onset date is before the onset date of statutory blindness.

3. Secondary diagnosis or Item 16B

When the evidence does not include a secondary diagnosis or no medical evidence is in the file, enter "0000" and “none” will show in block 16B. Use impairment code "6490" when medical evidence in the file is not sufficient to establish a diagnosis. The secondary diagnosis in all determinations is the most significant diagnosis following the primary diagnosis in severity, except in the following situations.

a. Symptomatic human immunodeficiency virus (HIV) infection

If the primary diagnosis is symptomatic HIV infection, enter the diagnosis of the most significant HIV-related complication as the secondary diagnosis. If there is no HIV-related complication, enter the most significant diagnosis following the primary diagnosis.

b. DAA is present but not material

When DAA is present but not material, enter “alcoholism” or “drug addiction,” as appropriate, as the secondary diagnosis.

c. Statutory blindness

Enter “Statutory Blindness” as the secondary diagnosis when the basis of the EOD (Item 15A) is not statutory blindness and the impairment’s onset date is before the onset date of statutory blindness.

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In Item 16A (Primary Diagnosis), enter the diagnosis of the other impairment at the established onset date. Enter the related body system code and diagnosis code.
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In Item 16B (Secondary Diagnosis), enter “Statutory Blindness” as the secondary diagnosis and show diagnosis code 3694. Because item 16B can only show “Statutory Blindness,” you cannot include the underlying cause on the SSA-831. Document additional information in a Case Note in the Disability Case Processing System (DCPS), or on the Case Development Worksheet (CDW).

REMINDER: For additional instructions about completing Item 18 (Case of Blindness), see DI 26510.025.

D. Body system coding

Body system coding of the primary diagnosis is required for all determinations, favorable or unfavorable.

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Obtain the appropriate body system code number for the primary diagnosis from DI 26510.015F in this section.
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Enter the 2-digit body-system code number in the designated space following the primary diagnosis in Item 16A.

E. Impairment coding

You must code the primary and secondary diagnosis for all determinations, favorable or unfavorable.

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Select codes, as appropriate, from the predetermined lists in DI 33526.000.
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Use the code in DI 33526.000 that most accurately identifies the impairment.
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Whenever symptomatic HIV (code 0430) is used as the primary diagnosis, use a code from DI 33526.070D as the secondary diagnosis for all favorable or unfavorable determinations, except as noted under DI 33526.070E..
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Never use a code from DI 33526.070D as a primary diagnosis. We designated these codes to use as a secondary diagnosis for HIV. Only use as a secondary diagnosis when the primary diagnosis is symptomatic HIV (code 0430).

To complete the impairment code number entry on the SSA-831, enter the appropriate 4-digit impairment code in the designated space following the primary diagnosis in Item 16A and the secondary diagnosis in Item 16B.

1. Primary diagnosis impairment codes

Situation	Reference
Meets, medical equals	DI 33526.000.
Medical and vocational allowances Functional equals allowances Denial Special situations	DI 33526.000.

2. Secondary diagnosis impairment codes

Situation	Reference
Meets, medical equals	DI 33526.000.
Medical and vocational allowances Functional equals allowances Denial Special situations	DI 33526.000.
Symptomatic HIV infection	DI 33526.070D.

F. List of body system codes

Code number	Body System
01	Musculoskeletal Disorders
02	Special Senses and Speech
03	Respiratory Disorders
04	Cardiovascular System
05	Digestive Disorders
06	Genitourinary Disorders
07	Hematological Disorders
08	Skin Disorders
09	Endocrine Disorders
10	Congenital Disorders That Affect Multiple Body Systems
11	Neurological Disorders
12	Mental Disorders
13	Cancer
14	Immune System Disorders
19	Low Birth Weight and Failure to Thrive
20	Special/Other

NOTE: Body system impairment codes are found in DI 33526.001, et seq.

Social Security

Program Operations Manual System (POMS)

DI 26510.015 Completing Item 16A and 16B (Primary and Secondary Diagnosis, Body System Code, and Impairment Code) on the SSA-831 Disability Determination and Transmittal